=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538612213
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JLD COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2016
-----------------------------------------------------
Last Update Date | 07/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5585 ERINDALE DR STE 201
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80918-6737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-393-5119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5585 ERINDALE DR STE 201
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80918-6737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-393-5119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SINGLE MEMBER
-----------------------------------------------------
Name | JAMIE L DANIELS
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 719-393-5119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT.0001281
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------